Provider Demographics
NPI:1801903232
Name:PEDIATRIC GASTROENTEROLOGY ASSOCIATES
Entity type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:IFEADIKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-508-5315
Mailing Address - Street 1:PO BOX 922401
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30010-2401
Mailing Address - Country:US
Mailing Address - Phone:404-508-5315
Mailing Address - Fax:404-508-5313
Practice Address - Street 1:465 WINN WAY
Practice Address - Street 2:SUITE 215
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1753
Practice Address - Country:US
Practice Address - Phone:404-508-5315
Practice Address - Fax:404-508-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0385519174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty